Prior to administering a drug to a patient, the drug may require transfer from a storage container to a drug delivery container. The storage container may be, for example, a single-dose drug container. The drug delivery container may be, for example, a syringe. Typically, after the drug is transferred to the syringe, the person carrying out the transfer sometimes prepares a label by hand and applies it to the syringe to indicate the drug now contained in the syringe. In some situations, pre-prepared labels are provided to eliminate the need for the person to manually prepare the label. Some systems have been provided whereby the person can type in the name of the drug into a computer to print a label instead of having to prepare the label manually.
Several different types of error can occur during this process all of which can lead to the syringe bearing a label indicating a different drug than is actually contained in the syringe. For example, the user can pull the wrong drug from a drug cabinet and prepare a label with the name of the drug they thought they pulled. This can occur particularly easily with certain drugs, because their colour and packaging may be quite similar.
Alternatively, the user may pull the correct drug from the drug cabinet, but may inadvertently prepare a label indicating the next drug that has to be prepared because that next drug is on the user's mind at the time. Another problem is that some drugs have very similar names to other drugs, which increases the risk that a user will mistake one drug for another.
Once a syringe is mis-labeled many problems can occur. If a patient receives the wrong drug, this can lead to catastrophic consequences. Unfortunately, doctors treating the patent might not find out the true cause of the patient's reaction and therefore would not be easily able to properly treat it.
A proposed solution to this problem has been to prepare and label syringes at the pharmacy and to send the drugs to the point of care in the syringes to eliminate the need for a repackaging step. A problem with this approach is that the drugs expire relatively quickly once they are in the syringe, and often the drug manufacturer is not certain how quickly. In many cases, the drug expires in a matter of hours.
Additionally, storage of the drug in a syringe over several hours can in some situations lead to chemicals contained in the syringe components (eg. housing, plunger and seal) leaching into the drug. If the patient reacts to these chemicals this can cause harm to the patient.
Additionally, in some environments, such as an operating room environment, it sometimes occurs that an unexpected drug is required to be administered to the patient. Either the drug has to be repackaged in the operating room with all of its inherent problems as described above, or the pharmacy has to prepare many extra syringes containing drugs to cover off unexpected situations. Whichever of these extra syringes is not used during the operation is discarded, since they cannot be repackaged with confidence in their expiry date or their safety. This practice is, of course, wasteful of the discarded drugs and may also be costly.